Adult Guidelines


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Abdomen

Abdomen

  1. The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO .
  2. Fungal Infection is an important consideration in patients with intra-abdominal sepsis.  In patients at high risk of fungal infection e.g. upper GI perforation, consider antifungal therapy; discuss with Microbiology or Infectious Diseases.
  3. Most patients with acute pancreatitis do NOT have necrotising pancreatitis and do NOT require antibiotic prophylaxis.

Empiric Antibiotics for Abdominal Infections

Infection

1 st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Intra-abdominal

Mild Community Acquired

e.g. cholecystitis/

appendicitis/

diverticulitis

Co-amoxiclav IV

1.2g every 8 hours

CefUROXime IV

1.5g every 8 hours

+

Metronidazole** IV 500mg every 8 hours

Ciprofloxacin** IV 400mg every 12 hours

+

Metronidazole** IV 500mg every 8 hours

Duration

4 to 7 days assuming adequate source control

Intra-abdominal

Moderate to Severe Community &

All Hospital Acquired

including

cholangitis/ intra-abdominal abscess/diverticulitis

Piperacillin/

tazobactam IV

4.5g every 8 hours

Add Gentamicin IV IF haemo-dynamically unstable. Give one dose per GAPP App calculator. See footnote* re further doses and monitoring.

CefTRIAXone IV

2g every 24 hours

+

Metronidazole** IV 500mg every 8 hours

Add Gentamicin IV IF haemodynamically unstable. Give one dose per GAPP App calculator. See footnote* re further doses and monitoring.

Ciprofloxacin** IV 400mg every 12 hours

+

Gentamicin IV one dose per GAPP App calculator. See footnote* re further doses and monitoring.

+

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

+

Metronidazole** IV 500mg every 8 hours

Discuss with Microbio-logy or Infectious Diseases.

Duration

7 to 10 days assuming adequate source control.

Necrotising Pancreatitis

Patients with acute pancreatitis admitted to ICU or necrotising pancreatitis confirmed by imaging

CefTRIAXone IV 2g every 24 hours

+

Metronidazole IV 500mg every 8 hours

Ciprofloxacin IV 400mg every 12 hours

+

Metronidazole IV

500mg every 8 hours

Review need for antibiotics every 72 hours. See note below.

Discuss with Microbiology or Infectious Diseases if deterioration or requiring antibiotics for more than 5 days

Spontaneous Bacterial Peritonitis

CefTRIAXone IV 2g every 24 hours

Ciprofloxacin** IV 400mg every 12 hours

5 days

Peritoneal Dialysis Peritonitis

Vancomycin Intraperitoneally 30mg/kg (max. 3g) loading dose, then 30mg/kg (max. 2g) every 5 to 7 days + Ciprofloxacin PO 500mg every 12 hours

  • Patient to be treated in PD Unit
  • Protocol and detailed guidelines available on QPulse & in PD Unit

Cirrhosis with Acute Variceal Haemorrhage, Prophylaxis

CefTRIAXone IV

2g every 24 hours

CefTRIAXone IV 2g every 24 hours

Ciprofloxacin PO

500mg every 12 hours

7 Days

Prophylaxis for patients with an absent or dysfunctional spleen

Phenoxymethyl-penicillin PO

666mg

(Calvepen ® )

every 12 hours
OR

Amoxicillin PO

500mg every 24 hours

Erythromycin PO

250 to 500mg every 24 hours

Oral absorption of phenoxymethylpenicillin is limited and affected by a number of variables. For emergency self initiated therapy of a suspected systemic infection treatment with amoxicillin is preferable.

See Appendix 3 for guidelines for management of patients with absent or dysfunctional spleen (adults only) including recommended vaccines & antibiotics.

Emergency treatment doses

Amoxicillin PO

500mg to 1g every 8 hours

Erythromycin PO

500mg to 1g every 6 hours

* Review need for ongoing Gentamicin and Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended. For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

**Switch  from IV to oral Ciprofloxacin and Metronidazole as soon as possible

Refs:

  1. IDSA Guidelines for Diagnosis and Management of Complicated Intra-abdominal infections in Adults & Children. Clin Infect Dis 2010;50:133-164
  2. ISPD Peritoneal dialysis-related infections: recommendations 2010 update. Peritoneal Dialysis International July 2010;30:393-423
  3. GUH Procedure for Treating a Patient with Peritonitis (QPulse CLN-NM-095)


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Bone and Joint

Bone and Joint

  1. Microbiological diagnosis is essential , relevant bone and synovial fluid samples should be sent prior to treatment. Treatment should be targeted at the infecting organism.
  2. Discussion with Microbiology or Infectious Diseases is recommended in all cases.
  3. The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO .

Empiric Antibiotics for Bone and Joint Infections

Infection

1 st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Septic Arthritis

Flucloxacillin IV

2g every 6 hours

OR

CefTRIAXone IV 2g every 24 hours ( IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus)

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

OR

CefTRIAXone IV 2g every 24 hours ( IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus)

Discuss with Microbiology or Infectious Diseases

Adequate drainage of joint fluid essential. Blood cultures also required. Gram stain may alter antibiotic therapy.

Discuss with Microbiology or Infectious Diseases.

Osteomyelitis

Discuss with Microbiology or Infectious Diseases; treat according to culture results.

Prosthetic Joint Infection

Discuss with Microbiology or Infectious Diseases; treat according to culture results.

*For advice on monitoring see Vancomycin Dosing & Monitoring section.

Ref:

  1. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults Rheumatology 2006;45:1039-1041



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Bacterial Endocarditis

Bacterial Endocarditis

  1. The following is intended primarily to provide initial short-term guidance on empiric therapy of seriously ill patients and those with prosthetic valves.
  2. Immediate discussion on the next day with Microbiology or Infectious Diseases is recommended in all cases of suspected endocarditis.
  3. In those with sub-acute presentation of suspected endocarditis, with a native valve and who are clinically stable at presentation it is often preferable to send blood cultures (as below) and to withhold antibiotics pending consultation and culture results.
  4. In all but the most profoundly ill patients take 3 sets of blood cultures (10ml into each of two bottles for each set) BEFORE any antibiotics are given. If the patient is seriously ill the interval between cultures can be as short as 20 or 30 minutes.

Empiric Antibiotics for Bacterial Endocarditis

Infection

1 st Line Antibiotics

Penicillin allergy: immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Bacterial Endocarditis

Native Valve or Prosthetic valve

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

+

Gentamicin IV 1mg/kg (maximum 80mg) every 12 hours. See footnote* re monitoring

+

CefTRIAXone IV 2g every 24 hours

Native Valve or Prosthetic valve

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

+

Gentamicin IV 1mg/kg (maximum 80mg) every 12 hours. See footnote* re monitoring

+

Ciprofloxacin PO 500mg every 12 hours (IV 400mg every 12 hours if NPO)

Once culture and sensitivity results are available direct antibiotic therapy accordingly in discussion with Microbiology or Infectious Diseases.

Duration as advised by Microbiology or Infectious Diseases.

* For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

Refs:

  1. Gould et al. BSAC Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults. Journal of Antimicrobial Chemotherapy 2012;67:269-289
  2. Baddour et al. AHA Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation 2015;132:1435-1486
  3. Habib et al. ESC Guidelines on the prevention, diagnosis & treatment of infective endocarditis. European Heart Journal 2015;36:3075-3128


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Prophylaxis of Infective Endocarditis

Prophylaxis of Infective Endocarditis

  1. The routine use of antibiotics in most situations is NOT justified on the balance of risk and benefit.
  2. Consult with Microbiology or Infectious Diseases recommended if infection at procedure site.
  3. Only patients identified with the following cardiac conditions undergoing one of the following high risk procedures should be considered for prophylaxis for infective endocarditis (IE):

Prophylaxis of Infective Endocarditis

Box 1: Cardiac conditions requiring endocarditis prophylaxis - for high risk procedures

  1. Prosthetic valve or prosthetic material used for cardiac valve repair.
  2. Previous infective endocarditis.
  3. Cardiac transplantation recipients who develop cardiac valvulopathy.
  4. Congenital heart disease (CHD):
  • Unrepaired cyanotic CHD, including palliative shunts and conduits
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure
  • Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialisation).

Box 2: Recommendations by procedure - for patients with identified cardiac conditions

A. Dental Procedures

Antibiotic prophylaxis should only be considered for dental procedures requiring manipulation of gingival or periapical region of teeth or perforation of oral mucosa.

Antibiotic prophylaxis is not recommended for local anaesthetic injections in non-infected tissue, removal of sutures, dental X-rays, placement or adjustment of removable prosthodontic or orthodontic appliances or braces, or following shedding of deciduous teeth, or trauma to lips or oral mucosa.

B. Respiratory Tract Procedures

Antibiotic prophylaxis should only be considered for invasive procedures involving incision or biopsy of the respiratory mucosa e.g. tonsillectomy or adenoidectomy, or to treat infection e.g. drainage of abscess or empyema.

Antibiotic prophylaxis is not recommended for respiratory tract procedures, including bronchoscopy or laryngoscopy, transnasal or endotracheal intubation.

C. Gastrointestinal or genitourinary tract procedures

Antibiotic prophylaxis is not recommended for any procedure.

Box 3: Recommended prophylaxis for procedures at risk

Give as a single dose 30 to 60 minutes before procedure

Procedure

1st line antibiotic

Alternative if penicillin allergic

Dental

Adult dose: Amoxicillin PO/IV 2g (can give 3g sachet)

Adult dose: Clindamycin PO/IV 600mg

Respiratory

As for dental

Refs:

  1. Wilson et al. AHA Guideline Prevention of Infective Endocarditis. Circulation 2007;116:1736
  2. Habib et al. ESC Guidelines on the prevention, diagnosis & treatment of infective endocarditis. European Heart Journal 2015;36:3075-3128


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Central Nervous System


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Suspected Bacterial Meningitis

Suspected Bacterial Meningitis

  1. The most important aspect of treatment of suspected or confirmed bacterial meningitis is to commence antibacterial therapy IMMEDIATELY .
  2. Chloramphenicol is available in the Emergency Department and in the Pharmacy Department. Meropenem may be an alternative to chloramphenicol in patients with a history of penicillin anaphylaxis, as recommended in Irish guidelines, with close monitoring for cross-sensitivity e.g. in ICU. Consult with immunology strongly advised.
  3. See footnote on use of Dexamethasone .
  4. Discuss with Microbiology or Infectious Diseases essential if risk factors for M. tuberculosis (alcohol, homelessness, immunocompromised host, recent immigration from area of high incidence, recent contact with tuberculosis) or if history of neurosurgery or head trauma or if device-related infection e.g central nervous system shunt, ventricular drain or other.
  5. Risk factors for Listeria monocytogenes meningitis in adults include underlying neoplasm, immunosuppressive treatment, age over 50, pregnancy and excessive alcohol use.
  6. See Appendix 4 for management of contacts.

Empiric Antibiotics for Suspected Bacterial Meningitis

Infection

1 st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Suspected Bacterial Meningitis

CefTRIAXone IV

2g every 12 hours

+

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re review and monitoring.

Consider adding Amoxicillin IV 2g every 4 hours if at risk for L. monocytogenes

(See point 5 above)

CefTRIAXone IV

2g every 12 hours

+

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re review and monitoring.

Consider adding

Co-trimoxazole IV 60mg/kg every 12 hours (round dose to nearest multiple of 480mg) if at risk for L. monocytogenes

(See point 5 above)

Chloramphenicol IV

25mg/kg

+

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re review and monitoring.

Give first doses, THEN IMMEDIATELY consult Microbiology or Infectious Diseases regarding further therapy.

Consider adding

Co-trimoxazole IV 60mg/kg every 12 hours (round dose to nearest multiple of 480mg) if at risk for L. monocytogenes

Discuss need for nasopharyngeal eradication for the patient with Microbiology or Infectious Diseases

(See point 5 above)

Minimum duration of treatment:

Meningococcal meningitis:

7 days

Haemophilus meningitis:

10 days

Pneumococcal meningitis:

14 days

Listeria meningitis:

21 days

* Review need for ongoing vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

Dexamethasone

  • Consider adjunctive treatment with dexamethasone IV 0.15mg/kg every 6 hours for four days (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibiotic, but no later than 24 hours after starting antibiotic.
  • Avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.
  • Some experts add Rifampicin PO 600mg every 12 hours to the antimicrobial regimen if Dexamethasone is given.


Refs:

  1. IDSA Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis 2004;39:1267–84
  2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including meningococcal disease) November 2016
  3. BNF 79 March 2020


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Suspected Herpes Simplex Encephalitis

Suspected Herpes Simplex Encephalitis

  1. Viral meningitis (as distinct from encephalitis) generally does NOT require anti-viral treatment. Discuss with Microbiology or Infectious Diseases.
  2. Consult with Microbiology or Infectious Diseases recommended if patient has recent travel history or is immunocompromised.

Antivirals for Suspected Herpes Simplex Encephalitis

Infection

1 st Line

Comment

Suspected

Herpes Simplex

Encephalitis

Aciclovir IV

10mg/kg every 8 hours

Refer to IV guide on MedinfoGalway for dosing in obese patients.

Confirmed HSV encephalitis requires a total of 14 to 21 days IV therapy.

Ref: IDSA Guidelines for the Management of Encephalitis Clin Infect Dis 2008;47:303-27



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Acute Bacterial Conjunctivitis

Acute Bacterial Conjunctivitis

  • Acute conjunctivitis can be classified as infectious (bacterial or viral) or non-infectious (allergic, toxic, or nonspecific). This guidance is specifically for acute non gonococcal, non chlamydia bacterial conjunctivitis.
  • Send a swab for culture and sensitivity. Antimicrobialal therapy is of very limited value in most cases of conjunctivitis. Most cases of bacterial conjunctivitis are self-limiting and often resolve within 5–7 days without treatment.
  • Topical chloramphenicol or fusidic acid may be used.
  • If concerned regarding chlamydia or gonococcal conjunctivitis discuss with Microbiology or Infectious Disease AND Ophthalmology.

Empiric Treatment of Acute Bacterial Conjunctivitis

Infection

Treatment

Comment

Acute Bacterial Conjunctivitis

Chloramphenicol 0.5% drops — apply 1 drop 2 hourly for 2 days then every 6 hours for 5 days.

Or

Chloramphenicol 1% ointment (Unlicensed) — apply every 6 hours for 2 days, then every 12 hours for 5 days.

Or

Fusidic acid 1% eye drops — can be used second line. Apply every 12 hours for 7 days.

Duration 5-7 days

Note risk of local hypersensitivity reaction to antimicrobial.

Refs:

  1. National Institute for Health and Care Excellence (2017) Conjunctivitis-infective (CKS)               Available at https://cks.nice.org.uk/conjunctivitis-infective


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Orbital and Periorbital Cellulitis

Orbital and Periorbital Cellulitis

See Orbital and Periorbital Cellulitis in Skin & Soft Tissue Infections Section


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Fungal

Fungal

  1. Medical assessment is required before prescribing antifungal therapy.
  2. For suspected oral candidiasis send a swab to microbiology to confirm fungal infection.
  3. For recurrent or refractory or severe infection send a repeat swab and discuss with Microbiology or Infectious Diseases.
  4. In immunocompromised patients a high index of suspicion of infection is advised.

Empiric Treatment of Fungal Infections

Infection

Treatment

Comment

Oropharyngeal candidiasis

Mild

Nystatin suspension PO

5ml every 6 hours after food. Swish and swallow, leaving in contact with mouth for at least 30 seconds.

Duration usually for 7 to 14 days

Moderate to severe

Fluconazole PO 100 - 200mg every 24 hours

Duration 7 to 14 days

Fluconazole refractory

Contact Microbiology or Infectious Diseases

Denture related

As above plus disinfection of dentures

Oesophageal

candidiasis

Fluconazole PO

200 - 400mg every 24 hours

Duration 14 to 21 days

Acute Vulvovaginal candidiasis (VVC)

Recommended regimen (Non-pregnant / non-breastfeeding):

Fluconazole capsule 150 mg as a single dose, orally

Recommended topical regimen (if oral therapy contraindicated):

Clotrimazole pessary 500 mg as a single dose, intravaginally

Acute VVC in Pregnancy and breastfeeding:

Clotrimazole pessary 500 mg intravaginally at night for up to 7 consecutive nights

Fluconazole refractory/ severe/ recurrent VVC

Contact Microbiology or Infectious Diseases

Candida at urinary, respiratory & other sites

Treatment not routinely indicated.

Contact Microbiology or Infectious Diseases

Disseminated candidiasis

Contact Microbiology or Infectious Diseases

Choice of antifungal depends on sensitivities.

Fungal skin infection

Contact Microbiology or Infectious Diseases or Dermatology for advice

Fungal nail infection

Contact Microbiology or Infectious Diseases or Dermatology for advice

For all other suspected fungal infections e.g. aspergillosis contact Microbiology or Infectious Diseases

Contact Microbiology or Infectious Diseases for advice

Refs:

  1. IDSA Candidiasis Guidelines Clin Infect Dis 2016;62:e1-e50
  2. British Association for Sexual Health and HIV (BASHH). British Association for Sexual Health and HIV national guideline for the management of vulvovaginal candidiasis (2019). BASHH, 2019.


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Gastrointestinal System


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Clostridioides difficile Infection (CDI)

Clostridioides difficile Infection (CDI)

  1. If on antibiotics: Stop the offending antibiotic(s) as soon as possible
  2. Start treatment for C. difficile empirically if patient is symptomatic
  3. See Algorithm for disease severity stratification and treatment of initial episode and first recurrence of CDI
  4. The following regimens may be recommended by Microbiology or Infectious Diseases only

Antibiotics for Clostridium difficile Infection

Infection

1st Line Antibiotics

Comment

Clostridioides difficile

Non-severe

Metronidazole PO/NG 400mg every 8 hours

  • If severe, failure to respond or second and subsequent episodes of recurrent CDI - discuss with Microbiology or Infectious Diseases.
  • Duration 10 to 14 days.
  • Maintain hydration.
  • Avoid anti-diarrhoeal agents.
  • Stop precipitating antibiotic(s) if possible or switch to agents less likely to be associated with CDI.
  • Stop proton pump inhibitors (PPIs) if possible.
  • Use vancomycin injection to prepare oral solution – see IV Guide.
  • Prescribe vancomycin capsules if required on discharge. HIGH TECH and expensive – not routinely stocked in community. Please contact ward and community pharmacy at least 24hrs prior to discharge to arrange supply.

Severe

Vancomycin PO/NG 125mg every 6 hours

Severe with ileus or toxic megacolon

Vancomycin PO/NG 500mg every 6 hours

+

Metronidazole IV 500mg every 8 hours

Clostridioides difficile

First recurrence

Treat according to severity as above

Clostridioides​ difficile

Second or more recurrence

Consult Microbiology or Infectious Diseases

Refs:

  1. Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland June 2014


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CDI Algorithm for disease severity stratification and treatment

(click on image to enlarge)


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Tapered pulsed oral Vancomycin

Tapered Pulsed Oral Vancomycin

  1. Requires Microbiology or Infectious Diseases approval
  2. Use vancomycin injection to prepare oral solution for inpatients – see IV Guide
  3. Prescribe vancomycin capsules on discharge. Note: HIGH TECH and expensive – not routinely stocked in community. Please contact ward and community pharmacy at least 24hrs prior to discharge to arrange supply.

Vancomycin

  • 125mg every 6 hours for 1 week, then
  • 125mg every 12 hours for 1 week, then
  • 125mg once daily for 1 week, then
  • 125mg every second day for 1 week, then
  • 125mg every three days for 2 weeks.

Ref: Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland June 2014


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Intracolonic Vancomycin

Intracolonic Vancomycin

  1. Requires Microbiology or Infectious Diseases approval
  2. Adapted from University of Washington
  3. Adjunctive therapy for failing Vancomycin therapy in severe CDI
  • 500mg of Vancomycin injection is reconstituted and added to 100ml of NaCl 0.9%
  • An 18G Foley catheter is inserted per rectum and the balloon is inflated
  • The Vancomycin solution is instilled into the rectum and retained for 60 minutes by clamping the catheter
  • Once retention time complete, the catheter is unclamped, the balloon deflated and the catheter removed
  • The process is repeated every 6 hours

Ref: Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland June 2014


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Gastroenteritis

Gastroenteritis

  1. Avoid antimicrobial agents unless there is clinical evidence of invasive disease.
  2. Consider viral causes if vomiting is a prominent symptom or if norovirus is active in the community or hospital.
  3. Maintain hydration.
  4. Avoid anti-diarrhoeal agents.
  5. Send stool sample (include travel history on the form if relevant).
  6. Antimicrobial treatment for gastroenteritis is generally pathogen directed.
  7. If there is gastroenteritis with clinical evidence of invasive disease, sepsis, colitis or a history of recent foreign travel or for men who have sex with men (MSM), discuss empiric therapy/management with Microbiology or Infectious Diseases to guide empiric antimicrobial therapy.

Reference:

IDSA 2017 Treatment guidelines for infectious diarrhoea: Clin Infect Dis 65:1963, 2017.


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Helicobacter pylori Infection

Helicobacter pylori Infection

  1. Seek advice from gastroenterologist if 1 st or 2 nd line eradication unsuccessful.
  2. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process.
  3. Bismuth and oxytetracycline are available in Ireland as unlicensed medicines (ULM) – and therefore not routinely stocked in community. Please contact ward and community pharmacy at least 24hrs prior to discharge to arrange supply.
  4. Newer generation PPIs, e.g. esomeprazole 40mg, are considered more effective than first generation PPIs.

Antibiotic regimens for Helicobacter pylori Eradication

1 st Line Helicobacter pylori eradication

1 st Line Triple Therapy

Penicillin allergy

Comment

Alternative 1 st Line Triple Therapy

With prior exposure to clarithromycin - Alternative 1 st Line Quadruple Therapy

Amoxicillin PO 1g every 12 hours

+

Clarithromycin PO 500mg every 12 hours

+

Proton pump inhibitor 1 every 12 hours

Metronidazole PO 400mg every 12 hours

+

Clarithromycin PO 500mg every 12 hours

+

Proton pump inhibitor 1 every 12 hours

Metronidazole PO 400mg every 8 hours

+

Oxytetracycline 2 PO 500mg every 6 hours (ULM)

+

Bismuth 2 120mg every 6 hours (ULM)

+

Proton pump inhibitor 1 every 12 hours

Duration:

14 days

2 nd line Helicobacter pylori eradication - if still infected after 1 st line therapy

Discuss with gastro-enterology

2 nd Line Triple Therapy

With prior  previous exposure to metronidazole - Alternative 2 nd Line Triple Therapy

Penicillin Allergy

Alternative 2 nd Line Triple Therapy - without prior exposure to quinolone

Alternative 2 nd Line Quadruple Therapy - with prior exposure to quinolone

Amoxicillin PO 1g every 12 hours

+

Metronidazole PO 400mg every 12 hours

+

Proton pump inhibitor 1 every 12 hours

Amoxicillin PO 1g every 12 hours

+

Oxytetracycline 2 PO 500mg every 6 hours (ULM)

OR

Levofloxacin PO 250mg every 12 hours

+

Proton pump inhibitor 1 every 12 hours

Metronidazole PO 400mg every 12 hours

+

Levofloxacin 250mg every 12 hours

+

Proton pump inhibitor 1 every 12 hours

Metronidazole PO 400mg every 8 hours

+

Oxytetracycline 2 PO 500mg every 6 hours (ULM)

+

Bismuth 2 120mg every 6 hours

(ULM)

+

Proton pump inhibitor 1 every 12 hours

1 Newer generation PPIs, e.g. esomeprazole 40mg, are considered more effective than first generation PPIs

2 Bismuth and oxytetracycline are available in Ireland as unlicensed medicines– and therefore not routinely stocked in community. Please contact ward and community pharmacy at least 24hrs prior to discharge to arrange supply.

Refs:

  1. Irish H. pylori Working Group European Journal of Gastroenterology & Hepatology: 2017;29(5):552–559
  2. NICE Clinical Guideline (CG184) Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management Oct 2019
  3. BNF 80. Accessed online via Medicines Complete Oct 2020
  4. The Sanford Guide to Antimicrobial Therapy Digital update Feb 2021


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Genital System

Genital System

Discuss with Infectious Diseases or Microbiology

Empiric Antibiotics for Genital System Infections

Infection

1 st Line Antibiotics

Penicillin allergy: immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Pelvic Inflammatory Disease -

Outpatient Treatment

Send a full STI screen including Chlamydia & Gonorrhoea

CefTRIAXone IM 1g single dose

+

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Ofloxacin PO 400mg every 12 hours (see Fluoroquinolone warning )

+

Metronidazole PO

400mg every 12 hours

Duration

14 days

Pelvic Inflammatory Disease -

Inpatient Treatment

Send a full STI screen including Chlamydia & Gonorrhoea

CefTRIAXone IV 2g every 24 hours

+

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Clindamycin IV 900mg every 8 hours

+

Gentamicin IV every 24 hours, dose per GAPP App calculator. See footnote* re review and monitoring.

Followed by

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Note: The initial IV regimen does not cover Chlamydia or Gonorrhoea. It is important to send a full STI screen.

Continue IV treatment for 24 hours after clinical improvement

Total duration of antibiotic therapy 14 days

Acute Prostatitis/

Epididymo-orchitis

If Sexually active

CefTRIAXone IM 1g single dose (or 2g IV if inpatient)

+

Doxycycline PO 100mg every 12 hours

Send urethral swabs for Chlamydia & Gonorrhoea if sexually active in past six months & refer to Sexually Transmitted Infection (STI) Clinic/Infectious Diseases.

Duration 10 to 14 days.

If Chlamydia PCR negative consider stopping doxycycline.

Consider mumps as aetiology.

Acute Prostatitis/

Epididymo-orchitis

If NOT sexually active

Ciprofloxacin PO 500mg every 12 hours (See Fluoroquinolone warning )​

IF patient appears septic treat as suspected bloodstream infection:

Add Gentamicin IV one dose per GAPP App calculator. See footnote* re further doses and monitoring.

Duration

14 to 28 days

* Review need for ongoing Gentamicin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended. For advice on monitoring see Aminoglycoside Dosing & Monitoring section.

Refs:

  1. BASHH UK National Guideline for the Management of Pelvic Inflammatory Disease (2019 Interim Update)
  2. BASHH UK National Guideline for the Management of Epididymo-orchitis 2019
  3. Prostatitis (acute): antimicrobial prescribing NICE guideline Published: 31 October 2018


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Intravascular Line

Intravascular Line

  1. Blood cultures should be taken if the patient appears septic and/or if the patient has a central or peripheral vascular catheter (CVC/PVC) exit site infection indicated by the presence of cellulitis or thrombophlebitis. One set of blood cultures from a peripheral vein and one set from all lumens of central line should be sent with clinical details included on the form.
  2. If evidence of exit site infection, a swab should be taken from the site and the line should be removed.
  3. In the setting of suspected central line infection, the tip of the central line should be sent to the microbiology lab in a universal container for culture and sensitivity testing, cut to 4 cm in length following removal.
  4. If blood cultures are positive discuss with Microbiology or Infectious Diseases.
  5. Infection at the site of CVC/PVC, with no systemic features of sepsis and with negative blood cultures may be treated as a skin/soft tissue infection. Treatment is as follows:
    • Removal of the catheter is essential
    • Initial therapy should be with Vancomycin
    • Review at 48 hours, and consider switch to Flucloxacillin or other antibiotic if appropriate, based on culture and sensitivity results and MRSA screens.
  6. An antibiotic lock solution is very occasionally recommended by Microbiology or Infectious Diseases. If indicated, contact pharmacy for protocol.

Empiric Antibiotics for Intravascular Line Infections

Infection

1 st Line

Comment

Central and Peripheral IV Catheter Exit Site Infection

See notes above

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

Review at 48 hours, change to pathogen directed therapy based on culture & sensitivity

Duration 7 to 10 days

Peripheral Line-related Infection and/or

Bacteraemia

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

Review at 48 hours, change to pathogen directed therapy based on culture & sensitivity

Duration minimum 14 days, for exceptions see algorithm for NON-tunnelled CVC bacteraemia

Central Line-related Infection and/or

Bacteraemia

Remove CVC and send tip to microbiology

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re monitoring.

+

Gentamicin IV one dose per GAPP App calculator and review . See footnote* re further doses and monitoring.

If blood cultures are positive treat as per Microbiology or Infectious Diseases advice.

Duration varies by type of line, organism and complications.  A prolonged course may be required.

See algorithms for NON-tunnelled CVC bacteraemia and tunnelled CVC/port bacteraemia

When denoting duration of antimicrobial therapy day 1 is the first day on which negative blood cultures are obtained.

* Review need for ongoing Gentamicin & Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended. For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

Refs:

  1. HSE/RCPI/HCAI Prevention of Intravascular Catheter-related Infection in Ireland Partial Update of 2009 Guidelines September 2014
  2. IDSA Guidelines for the diagnosis and management of intravascular catheter-related infection. Clin Infect Dis 2009;49:1-45


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Algorithm for Management of NON-tunnelled CVC Bacteraemia

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Algorithm for Management of Tunnelled CVC / Port Bacteraemia

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Malaria

Malaria

  1. Discussion with Infectious Diseases or Microbiology recommended.
  2. Species of infecting parasite is frequently uncertain.
  3. Severe malaria is a medical emergency. After rapid clinical assessment, a diagnostic test should be sent. In patients with clinically severe malaria or high parasitaemia (2% or greater) first line treatment is intravenous Artesunate which should be started within one hour of assessment. Intravenous Quinine (Unlicensed) may be used if Artesunate is unavailable for any reason.
  4. Follow-on therapy Note for some kinds of malaria additional follow on therapy with Primaquine is required to eradicate the persistent liver stage.  All cases must be discussed with Infectious Diseases or Microbiology.
  5. Discharge prescriptions There are frequent problems with availability and medical card coverage of oral treatment on discharge. Please contact ward and community pharmacy at least 24hrs prior to discharge to arrange supply.

Malaria Treatment

Indication

Oral Antimalarials

Comment

1 st Line

2 nd & 3 rd line

Non-severe malaria

Non-Pregnant Adult

Riamet ® PO (over 35kg body weight) 4 tablets at 0,8,24,36,48,60 hours (total 24 tablets over 60 hours)

(Four tablets of Riamet ® contain 80mg of Artemether & 480mg of Lumefantrine)

Second line:

Malarone ® PO 4 tablets every 24 hours for 3 days

(Four tablets of Malarone ® contain 1g of Atovaquone & 400mg of Proguanil)

OR

Third line option - non-pregnant adult only:

Quinine PO 600mg (Unlicensed)

every 8 hours

+

Doxycycline PO 200mg

every 24 hours

Duration 7 days

Avoid quinine if hypersensitive

Non-severe malaria

Pregnant Adult

1 st Trimester:

Quinine PO 600mg

every 8 hours

+

Clindamycin PO 450mg

every 8 hours

Duration 7 days

2 nd & 3 rd trimester

Riamet ® PO - dosing as above

Severe Malaria

Treat as a medical emergency. See notes above.

Intravenous Antimalarials: If seriously ill or unable to take tablets

Comment

1 st Line

2 nd line (if artesunate not available). Avoid quinine if hypersensitive.

Artesunate IV 2.4mg/kg at 0, 12, 24 hours, then every 24 hours until oral treatment can be substituted (see below).

Quinine IV infusion (Unlicensed)

Loading dose*: 20mg/kg (maximum 1.4g) infused over 4 hours, followed 8 hours after start of the loading dose by Maintenance dose: 10mg/kg (maximum 700mg) IV Infusion (over 4 hours) every 8 hours

Reduce maintenance dose to

5 to 7 mg/kg (maximum 700mg) every 8 hours in severe renal impairment, severe hepatic impairment, or if IV treatment continues for more than 48 hours.

*Do NOT give loading dose if patient has received quinine or mefloquine in previous 12 hours

Oral switch after 24 hours: see below.

Give intravenous antimalarials in the treatment of severe malaria for a minimum of 24 hours - irrespective of the patient’s ability to tolerate oral medication earlier.

Quinine toxicity: ECG monitoring required in the elderly and patients with cardiac disease

Significant risk of hypoglycaemia with IV quinine. Monitor blood glucose regularly (about every 2 hours) in the acute situation.

Switch to oral therapy after the first 24 hours (3 doses) to complete a full oral course when the patient is able to swallow AND retain oral medication reliably by giving a course of Riamet ® PO (dosing as above) for three days. See above for other oral options.

Refs

  1. WHO Guidelines for Malaria Feb 2021
  2. BNF 80 September 2021
  3. Lalloo et al UK malaria treatment guidelines 2016 Journal of Infection 72:635-649



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Neutropenic Sepsis

Neutropenic Sepsis

  1. Any suspicion of neutropenia and fever OR clinical signs of sepsis must be assessed immediately as an emergency
  2. Fever means temperature ≥38.3ºC on one occasion or sustained temperature greater than 38ºC.
  3. Neutropenia means an absolute neutrophil count of less than 0.5 X 10 9 /L.
  4. Administer antimicrobials promptly once sepsis is suspected.    HSE Sepsis Programme Documents & Resources are available at https://www.hse.ie/eng/about/who/cspd/ncps/sepsis/resources/
  5. Note frequent review is essential. The time frames suggested for addition of additional empiric therapy may need to be shortened if the patient’s condition is deteriorating.
  6. Consider risk for fungal infection and viral infection.
  7. If the infection is CVC associated - remove the CVC .
  8. Review previous microbiology for history of colonisation or infection with antibiotic resistant organisms and assess other risk factors for antibiotic resistance. If colonised with Multi-drug Resistant Organisms (MDRO) including Carbapenemase Producing Enterobacteriacae (CPE), discuss with Microbiology or Infectious Diseases.
  9. Comprehensive Haematology Guidelines are available on QPulse.
  10. Summary treatment algorithms:

Refs:

  1. IDSA Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2011;52:e56-93
  2. GUH Haematology Guidelines for the management of febrile neutropenic patients (QPulse CLN-HAEM-020)
  3. NICE Neutropenic Sepsis: prevention and management in people with cancer ( Clinical guideline 151 ) 2012
  4. Sepsis 3 Form Adult In-patient Feb 8, 2018


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Initial management of neutropenic sepsis - Algorithm

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Continuing management of neutropenic sepsis - Algorithm

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Obstetrics

Obstetrics

  1. These are summary empiric antibiotic choices. For full detailed guidance see Women’s and Children’s (WAC) Directorate Guidelines on QPulse. See listed references below.
  2. Discussion with Microbiology or Infectious Diseases recommended for patients showing signs of sepsis.
  3. Identify need for further intervention to address the source of infection e.g. drainage or removal of source.
  4. The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO .
  5. Duration of treatment & oral switch is decided on a case-by-case basis depending on subsequent diagnosis as well as clinical progress.

Empiric Antibiotics for Obstetric Infections

Infection

1 st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO

Chorioamnionitis

Discuss considerations around delivery with consultant obstetrician

Or

Endometritis (Post-partum)

If systemically septic follow antibiotic treatment for sepsis

Co-amoxiclav IV 1.2g every 8 hours

+

Gentamicin IV one dose per GAPP App calculator (use booking weight). See footnote* re further doses and monitoring

CefTRIAXone IV

2g every 24 hours

+

Gentamicin IV one dose per GAPP App calculator (use booking weight). See footnote* re further doses and monitoring

+

Metronidazole IV 500mg every 8 hours

Discuss with Microbiology or Infectious Diseases

Ciprofloxacin IV 400mg every 12 hours. See footnote^ re use in pregnancy

+

Gentamicin IV one dose per GAPP App calculator (use booking weight). See footnote* re further doses and monitoring See footnote^ re use in pregnancy.

+

Vancomycin IV infusion, dose per GAPP App calculator (use booking weight). See footnote* re monitoring

+

Metronidazole IV 500mg every 8 hours

Intrapartum Antibiotic Prophylaxis (IAP)

For full detailed guidance see WAC Directorate Guidelines and Procedure for the Management of Group B Streptococus (QPulse CLN-LW-0033)

Preterm Prelabour R upture of Membranes

With NO evidence of sepsis/

Chorioamnionitis

For full detailed guidance see  WAC Directorate Preterm Prelabour Rupture of Membranes (PPROM) (QPulse CLN-LW-0012)

Duration 10 days

Erythromycin PO 250mg every 6 hours

Mastitis

For full detailed guidance see WAC Directorate Guideline on the Management of Mastitis and Breast Abscess in the Lactating  Woman (QPulse CLN-OGCP-275)

See Skin/Soft Tissue Section for summary empiric treatment options for Cellulitis / Mastitis

Sepsis

For full detailed guidance, including antibiotics , see WAC Directorate Guideline on the Management of Suspected Sepsis and Sepsis in Obstetric Care (QPulse CLN-OGCP-218)

See Sepsis Section for summary empiric treatment options for Sepsis in pregnancy (includes options in penicillin allergy )

Urinary Tract Infection

For full detailed guidance see WAC Directorate Management of Urinary Tract Infections  in Pregnancy (QPulse CLN-OGCP-227)

See Urinary Tract Section for summary empiric treatment options for acute pyelonephritis in pregnancy

^Gentamicin & Ciprofloxacin are recommended in pregnancy when benefit outweighs risk.

* Gentamicin is generally NOT recommended in pregnancy unless benefit outweighs risk. Review need for ongoing Gentamicin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant / Specialist Registrar recommended. For advice on monitoring see Gentamicin Dosing & Monitoring section.

Refs:

  1. WAC Directorate Guideline on the Management of Mastitis and Breast Abscess in the Lactating  Woman (QPulse CLN-OGCP-275)
  2. WAC Directorate Guideline on the Management of Suspected Sepsis and Sepsis in Obstetric Care (QPulse CLN- OGCP-218)
  3. WAC Directorate Management of Urinary Tract Infections (UTI’s) in Pregnancy (QPulse CLN-OGCP-227)
  4. WAC Directorate Preterm Prelabour Rupture of Membranes (PPROM) (QPulse CLN-LW-0012)
  5. WAC Directorate Guideline on the Management of Pyrexia in Labour (QPulse CLN-LW-0034)
  6. WAC Directorate Guideline and Procedure for the Management of Group B Streptococus (QPulse CLN-LW-0033)
  7. RCOG Bacterial Sepsis in & following Pregnancy, Green-top Guidelines 64a & 64b 2 012
  8. CDC 2010 Guidelines for the Prevention of Perinatal Group B Streptococcal Disease
  9. RCOG Group B Streptococcal Disease, early-onset, Green-top Guideline 36 2017



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Community Acquired Pneumonia

Community Acquired Pneumonia (CAP)

  1. Give antibiotics as soon as possible, within 4 hours of presentation in the Emergency Department.
  2. The CURB-65 score, in conjunction with clinical judgement, is a severity assessment tool for Community Acquired Pneumonia (CAP). See Clinical Pathway below.
  3. Send sputum culture if severe infection OR risk factors for MRSA or Pseudomonas infection as follows:
    • ICU admission
    • Hospitalised and/or IV antibiotics within past 90 days
    • Previous Infection with MRSA or Pseudomonas
  4. Antibiotics are NOT usually recommended for exacerbation of asthma with normal chest X-ray.
  5. Antibiotics are NOT generally recommended for acute bronchitis with normal CXR - but consider for patients >75years, or those with diabetes, heart failure or immunocompromised.
  6. Nursing home patients presenting with pneumonia should be treated as CAP unless history of Multi-drug resistant organisms or within 14 days of discharge from hospital.

Empiric Antibiotics for Community Acquired Pneumonia (CAP)

Infection

1 st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Community Acquired Pneumonia (including nursing home patients unless history of MDRO or within 14 days of discharge from hospital).

See note on MDRO

Signs and symptoms of LRTI

AND new consolidation on chest X-ray

Mild CURB-65 Score 0 or 1

Amoxicillin PO

1g every 8 hours

In younger patients

Add atypical cover with

Clarithromycin PO

500mg every 12 hours

Doxycycline PO 100mg every 12 hours

Avoid Doxycycline in pregnancy or breast-feeding. Discuss with Micro/ID.

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Moderate CURB-65 Score 2

Amoxicillin PO/IV

1g every 8 hours

+

Clarithromycin PO

(IV if NPO) 500mg every 12 hours

Levofloxacin PO (IV if NPO)

500mg every 12 hours

Avoid Levofloxacin in pregnancy or breast-feeding. Discuss with Micro/ID. Caution if risks for prolonged QT interval

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days )

Most patients can be treated with oral antibiotics

Severe CURB-65 Score ≥ 3

Co-amoxiclav IV

1.2g every 8 hours

+

Clarithromycin PO

(IV if NPO) 500mg every 12 hours

CefTRIAXone IV

2g every 24 hours

+

Clarithromycin PO (IV if NPO) 500mg every 12 hours

Levofloxacin PO

(IV if NPO) 500mg every 12 hours

+

Consider adding

Vancomycin IV infusion, IF at risk of Staph aureus infection. Dose per GAPP App calculator. See footnote* re review and monitoring.

Avoid levofloxacin in pregnancy or breastfeeding. Discuss with Micro/ID. Caution if risks for prolonged QT interval.

Duration

7 days

May need to be extended to 14 or 21 days according to clinical judgement e.g. if Legionella pneumophila, Staphylococcus aureus or Gram-negative bacilli suspected or confirmed.

* Review need for ongoing vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

References:

  1. British Thoracic Society Guidelines for the management of community acquired pneumonia in adults 2009
  2. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care 2019;200(7):e45–e67
  3. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Intern Med 2016;176(9):1257-1265


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Clinical pathway for management of Community Acquired Pneumonina in GUH